Causes and consequences of child growth faltering in low-resource settings.

Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.

Dietary diversity moderates household economic inequalities in the double burden of malnutrition in Tanzania.

OBJECTIVE: Improved food availability and a growing economy in Tanzania may insufficiently decrease pre-existing nutritional deficiencies and simultaneously increase overweight within the same individual, household or population, causing a double burden of malnutrition (DBM). We investigated economic inequalities in DBM at the household level, expressed as a stunted child with a mother with overweight/obesity, and the moderating role of dietary diversity in these inequalities. DESIGN: We used cross-sectional data from the 2015-2016 Tanzania Demographic and Health Survey. SETTING: A nationally representative survey. PARTICIPANTS: Totally, 2867 children (aged 6-23 months) and their mothers (aged 15-49 years). The mother-child pairs were categorised into two groups based on dietary diversity score: achieving and not achieving minimum dietary diversity. RESULTS: The prevalence of DBM was 5·6 % (sd = 0·6) and significantly varied by region (ranging from 0·6 % to 12·2 %). Significant interaction was observed between dietary diversity and household wealth index (Pfor interaction < 0·001). The prevalence of DBM monotonically increased with greater household wealth among mother-child pairs who did not achieve minimum dietary diversity (Pfor trend < 0·001; however, this association was attenuated in those who achieved minimum dietary diversity (Pfor trend = 0·16), particularly for the richest households (P = 0·44). Analysing household wealth index score as a continuous variable yielded similar results (OR (95 % CI): 2·10 (1·36, 3·25) for non-achievers of minimum dietary diversity, 1·38 (0·76, 2·54) for achievers). CONCLUSIONS: Greater household wealth was associated with higher odds of DBM in Tanzania; however, the negative impact of household economic status on DBM was mitigated by minimum dietary diversity.

Economic effects of the double burden of malnutrition.

Observations from many countries indicate that multiple forms of malnutrition might coexist in a country, a household, and an individual. In this Series, the double burden of malnutrition (DBM) encompasses undernutrition in the form of stunting, and overweight and obesity. Health effects of the DBM include those associated with both undernutrition, such as impaired childhood development and greater susceptibility to infectious diseases, and overweight, especially in terms of increased risk of added visceral fat and increased risk of non-communicable diseases. These health effects have not been translated into economic costs for individuals and economies in the form of lost wages and productivity, as well as higher medical expenses. We summarise the existing approaches to modelling the economic effects of malnutrition and point out the weaknesses of these approaches for measuring economic losses from the DBM. Where population needs suggest that nutrition interventions take into account the DBM, economic evaluation can guide the choice of so-called double-duty interventions as an alternative to separate programming for stunting and overweight. We address the evidence gap with an economic analysis of the costs and benefits of an illustrative double-duty intervention that addresses both stunting and overweight in children aged 4 years and older by providing school meals with improved quality of diet. We assess the plausibility of our method and discuss how improved data and models can generate better estimates. Double-duty interventions could save money and be more efficient than single-duty interventions.

Examining calorie undernourishment in India: Is it due to choice or inadequacy?

BACKGROUND: Calorie undernourishment is often associated with poverty but India presents a unique scene of decline in money-metric poverty and rise in calorie deprivation. Existing literature has varied explanation towards this effect. However, neither are the poor entirely calorie compromised nor do all the non-poor qualify calorie compliance. AIM: This is an attempt at verifying whether calorie undernourishment is a result of choice of food basket or the inadequacy of food expenditure. METHOD: An answer to this question is attempted with the exploration of data obtained from the National Sample Survey Organization's Consumption Expenditure of Indian households for the periods 2004-2005 and 2011-2012. RESULTS: Findings reveal that over the last one decade, the average per capita per day calorie intakes have slightly increased from 2040.55 Kcal in 2004-2005 to 2087.33 Kcal in 2011-2012, which has led to the increased share of well-nourished households from 20.21% in the 61st round to 22.78% in the 68th round of survey in rural areas, whereas the similar increase in urban areas is from 36.1% to 40.65%. CONCLUSIONS: Calorie undernourishment among the non-poor is observed that calorie undernourishment, if any, among the non-poor is entirely due to choice but the same among the poor has a divide between choice and inadequacy. The urban poor are calorie compromised more due to choice rather than inadequacy as against their rural counterparts. With higher poverty, calorie, non-compliance among the poor is more due to choice when compared with lower magnitude of poverty. These observations form a basis for contesting the common understanding that calorie compromise is entirely driven by inadequacy/incapacity of food expenditure. could be viewed in terms of the food choices made, especially among the poor while setting the minimum threshold of food expenditure to be calorie compliant.

A simplified, combined protocol versus standard treatment for acute malnutrition in children 6-59 months (ComPAS trial): A cluster-randomized controlled non-inferiority trial in Kenya and South Sudan.

BACKGROUND: Malnutrition underlies 3 million child deaths worldwide. Current treatments differentiate severe acute malnutrition (SAM) from moderate acute malnutrition (MAM) with different products and programs. This differentiation is complex and costly. The Combined Protocol for Acute Malnutrition Study (ComPAS) assessed the effectiveness of a simplified, unified SAM/MAM protocol for children aged 6-59 months. Eliminating the need for separate products and protocols could improve the impact of programs by treating children more easily and cost-effectively, reaching more children globally. METHODS AND FINDINGS: A cluster-randomized non-inferiority trial compared a combined protocol against standard care in Kenya and South Sudan. Randomization was stratified by country. Combined protocol clinics treated children using 2 sachets of ready-to-use therapeutic food (RUTF) per day for those with mid-upper arm circumference (MUAC) < 11.5 cm and/or edema, and 1 sachet of RUTF per day for those with MUAC 11.5 to <12.5 cm. Standard care clinics treated SAM with weight-based RUTF rations, and MAM with ready-to-use supplementary food (RUSF). The primary outcome was nutritional recovery. Secondary outcomes included cost-effectiveness, coverage, defaulting, death, length of stay, and average daily weight and MUAC gains. Main analyses were per-protocol, with intention-to-treat analyses also conducted. The non-inferiority margin was 10%. From 8 May 2017 to 31 March 2018, 2,071 children were enrolled in 12 combined protocol clinics (mean age 17.4 months, 41% male), and 2,039 in 12 standard care clinics (mean age 16.7 months, 41% male). In total, 1,286 (62.1%) and 1,202 (59.0%), respectively, completed treatment; 981 (76.3%) on the combined protocol and 884 (73.5%) on the standard protocol recovered, yielding a risk difference of 0.03 (95% CI -0.05 to 0.10, p = 0.52; per-protocol analysis, adjusted for country, age, and sex). The amount of ready-to-use food (RUTF or RUSF) required for a child with SAM to reach full recovery was less in the combined protocol (122 versus 193 sachets), and the combined protocol cost US$123 less per child recovered (US$918 versus US$1,041). There were 23 (1.8%) deaths in the combined protocol arm and 21 (1.8%) deaths in the standard protocol arm (adjusted risk difference 95% CI -0.01 to 0.01, p = 0.87). There was no evidence of a difference between the protocols for any of the other secondary outcomes. Study limitations included contextual factors leading to defaulting, a combined multi-country power estimate, and operational constraints. CONCLUSIONS: Combined treatment for SAM and MAM is non-inferior to standard care. Further research should focus on operational implications, cost-effectiveness, and context (Asia versus Africa; emergency versus food-secure settings). This trial is complete and registered at ISRCTN (ISRCTN30393230). TRIAL REGISTRATION: The trial is registered at ISRCTN, trial number ISRCTN30393230.

The Benefits of Parenteral Nutrition (PN) Versus Enteral Nutrition (EN) Among Adult Critically Ill Patients: What is the Evidence? A Literature Review.

Malnutrition is frequently seen among patients in the intensive care unit. Evidence shows that optimal nutritional support can lead to better clinical outcomes. Recent clinical trials debate over the efficacy of enteral nutrition (EN) over parenteral nutrition (PN). Multiple trials have studied the impact of EN versus PN in terms of health-care cost and clinical outcomes (including functional status, cost, infectious complications, mortality risk, length of hospital and intensive care unit stay, and mechanical ventilation duration). The aim of this review is to address the question: In critically ill adult patients requiring nutrition support, does EN compared to PN favorably impact clinical outcomes and health-care costs?

Impact of stakeholder perspectives on cost-effectiveness estimates of four specialized nutritious foods for preventing stunting and wasting in children 6-23 months in Burkina Faso.

BACKGROUND: Multiple specialized nutritious food options are programmed for supplementation in humanitarian and development settings. However, comparative cost-effectiveness evidence is lacking, let alone incorporation of perspectives from uncompensated stakeholders. A Burkina Faso trial evaluated the cost-effectiveness of Corn Soy Blend Plus w/ oil (CSB+ w/oil, reference arm), Corn Soy Whey Blend w/oil (CSWB w/oil), Super Cereal Plus (SC+), and Ready-to-Use Supplementary Food (RUSF) in reducing stunting and wasting among children 6-23 months old. This paper presents cost-effectiveness findings from multiple stakeholders' perspectives, including caregivers and program volunteers. METHODS: An activity-based costing with ingredients approach was used to summarize cost of the 18-month-long blanket supplementary feeding for each enrolled child (in 2018 USD). Time data were collected using self-reported and observational instruments. Cost-effectiveness relative to CSB+ w/oil assessed incremental cost per enrolled child against incremental outcomes: prevalence of stunting at 23 months of age and number of months of wasting. Two combined perspectives were compared: program (donor, implementer, and volunteer) versus program and caregiver (adding caregiver). RESULTS: A total of 6112 children were enrolled. While similar effectiveness was found in three arms (CSWB w/oil was less effective), costs differed. Product cost and caregiver time to prepare study foods were major drivers of cross-arm cost differences from the respective combined perspective. The two major drivers were used to construct uncertainty ranges of cost per enrolled child from program and caregiver perspective: $317 ($279- $355) in CSB+ w/oil, $350 ($327- $373) in CSWB w/oil, $387 ($371- $403) in RUSF, and $434 ($365- $503) in SC+. Cost from program and caregiver perspective was a substantial increase from program perspective. CSB+ w/oil was most cost-effective in reducing stunting and wasting, and this main finding was robust to changing perspectives and all corresponding sensitivity analyses when uncompensated time was valued at minimum wage ($0.36/h). The break-even point for uncompensated time valuation is >$0.84/h, where RUSF became the most cost-effective from the program and caregiver perspective. Relative cost-effectiveness rankings among the other three arms depended on choice of perspectives, and were sensitive to values assigned to product cost, international freight cost, opportunity cost of time, and outcomes of a hypothetical control. Volunteer opportunity cost did not affect arm comparisons, but lack of compensation resulted in negative financial consequences for caregivers. CONCLUSIONS: Evaluating cost-effectiveness by incorporating uncompensated stakeholders provided crucial implementation insights around nutrition products and programming. TRIAL REGISTRATION: Trial registration number: NCT02071563. Name of registry: ClinicalTrials.gov URL of registry: https://clinicaltrials.gov/ct2/show/NCT02071563?type=Intr&cond=Malnutrition&cntry=BF&draw=2&rank=9 Date of registration: February 26, 2014. Date of enrollment of first participant: July 2014.

Current diagnosis-related group-based bundling for upper-extremity arthroplasty: a case of insufficient risk adjustment and misaligned incentives.

BACKGROUND: The current Centers for Medicare & Medicaid Services diagnosis-related group (DRG) bundled-payment model for upper-extremity arthroplasty does not differentiate between the type of arthroplasty (anatomic total shoulder arthroplasty [ATSA] vs. reverse total shoulder arthroplasty vs. total elbow arthroplasty [TEA] vs. total wrist arthroplasty) or the diagnosis and indication for surgery (fracture vs. degenerative osteoarthritis vs. inflammatory arthritis). METHODS: The 2011-2014 Medicare 5% Standard Analytical Files (SAF5) database was queried to identify patients undergoing upper-extremity arthroplasty under DRG-483 and -484. Multivariate linear regression modeling was used to assess the marginal cost impact of patient-, procedure-, diagnosis-, and state-level factors on 90-day reimbursements. RESULTS: Of 6101 patients undergoing upper-extremity arthroplasty, 3851 (63.1%) fell under DRG-484 and 2250 (36.9%) were classified under DRG-483. The 90-day risk-adjusted cost of an ATSA for degenerative osteoarthritis was $14,704 ± $655. Patient-level factors associated with higher 90-day reimbursements were male sex (+$777), age 75-79 years (+$740), age 80-84 years (+$1140), and age 85 years or older (+$984). Undergoing a TEA (+$2175) was associated with higher reimbursements, whereas undergoing a shoulder hemiarthroplasty (-$1000) was associated with lower reimbursements. Surgery for a fracture (+$2354) had higher 90-day reimbursements. Malnutrition (+$10,673), alcohol use or dependence (+$6273), Parkinson disease (+$4892), cerebrovascular accident or stroke (+$4637), and hyper-coagulopathy (+$4463) had the highest reimbursements. In general, states in the South and Midwest had lower 90-day reimbursements associated with upper-extremity arthroplasty. CONCLUSIONS: Under the DRG-based model piloted by the Centers for Medicare & Medicaid Services, providers and hospitals would be reimbursed the same amount regardless of the type of surgery (ATSA vs. hemiarthroplasty vs. TEA), patient comorbidity burden, and diagnosis and indication for surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Lack of risk adjustment for fracture indications leads to strong financial disincentives within this model.

Clinical outcomes and financial impacts of malnutrition in sepsis.

BACKGROUND: In the United States in 2014 approximately 1.7 million adults were hospitalized with sepsis, resulting in about 270,000 deaths. Malnutrition in hospitalized patients contributes to increased morbidity, mortality, and costs, especially in the critically ill population. AIM: Our goal was to investigate the prevalence of malnutrition in sepsis and the impact it has on clinical and financial outcomes in our most critically ill patients. METHODS: We implemented nutritional screening by a registered dietitian of 1000 patients admitted with sepsis to specialized care units. We calculated the prevalence of malnutrition, and compared outcomes including mortality, length of stay, and financial costs. RESULTS: About 10% of patients with sepsis admitted to our specialized care units were diagnosed with malnutrition on admission after implementation of mandatory assessment. CONCLUSIONS: Although mortality did not reach statistical significance, these patients had more comorbidities, longer hospital stays, and higher total costs.

The Relative Caloric Prices of Healthy and Unhealthy Foods Differ Systematically across Income Levels and Continents.

BACKGROUND: Relative prices of healthy/unhealthy foods have been implicated in the obesity epidemic, but never extensively quantified across countries or empirically linked to undernutrition. OBJECTIVES: This study compared relative caloric prices (RCPs) for different food categories across 176 countries and ascertained their associations with dietary indicators and nutrition outcomes. METHODS: We converted prices for 657 standardized food products from the 2011 International Comparison Program into caloric prices using USDA Food Composition tables. We classified products into 21 specific food groups. We constructed RCPs as the ratio of the 3 cheapest products in each food group, relative to the weighted cost of a basket of starchy staples. We analyzed RCP differences across World Bank income levels and regions and used cross-country regressions to explore associations with Demographic Health Survey dietary indicators for women 15-49 y old and children 12-23 mo old and with WHO indicators of the under-5 stunting prevalence and adult overweight prevalence. RESULTS: Most noncereal foods were relatively cheap in high-income countries, including sugar- and fat-rich foods. In lower-income countries, healthy foods were generally expensive, especially most animal-sourced foods and fortified infant cereals (FICs). Higher RCPs for a food predict lower consumption among children for 7 of 9 food groups. Higher milk and FIC prices were positively associated with international child stunting patterns: a 1-SD increase in milk prices was associated with a 2.8 percentage point increase in the stunting prevalence. Similarly, a 1-SD increase in soft drink prices was associated with a reduction in the overweight prevalence of ∼3.6 percentage points. CONCLUSIONS: Relative food prices vary systematically across countries and partially explain international differences in the prevalences of undernutrition and overweight adults. Future research should focus on how to alter relative prices to achieve better dietary and nutrition outcomes.

Medical Nutrition Terminology and Regulations in the United States and Europe-A Scoping Review: Report of the ISPOR Nutrition Economics Special Interest Group.

BACKGROUND: The term medical nutrition (MN) refers to nutritional products used under medical supervision to manage disease- or condition-related dietary needs. Standardized MN definitions, aligned with regulatory definitions, are needed to facilitate outcomes research and economic evaluation of interventions with MN. OBJECTIVES: Ascertain how MN terms are defined, relevant regulations are applied, and to what extent MN is valued. METHODS: ISPOR's Nutrition Economics Special Interest Group conducted a scoping review of scientific literature on European and US MN terminology and regulations, published between January 2000 and August 2015, and pertinent professional and regulatory Web sites. Data were extracted, reviewed, and reconciled using two-person teams in a two-step process. The literature search was updated before manuscript completion. RESULTS: Of the initial 1687 literature abstracts and 222 Web sites identified, 459 records were included in the analysis, of which 308 used MN terms and 100 provided definitions. More than 13 primary disease groups as per International Classification of Disease, Revision 10 categories were included. The most frequently mentioned and defined terms were enteral nutrition and malnutrition. Less than 5% of the records referenced any MN regulation. The health economic impact of MN was rarely and insufficiently (n = 19 [4.1%]) assessed, although an increase in economic analyses was observed. CONCLUSIONS: MN terminology is not consistently defined, relevant European and US regulations are rarely cited, and economic evaluations are infrequently conducted. We recommend adopting consensus MN terms and definitions, for example, the European Society for Clinical Nutrition and Metabolism consensus guideline 2017, as a foundation for developing reliable and standardized medical nutrition economic methodologies.

Malnutrition risks and their associated factors among home-living older Chinese adults in Hong Kong: hidden problems in an affluent Chinese community.

BACKGROUND: Although China is undergoing rapid economic development, it is facing an ageing population. No data exists on malnutrition risks of older adults in an affluent Chinese society. The aim of this study is to examine these risks and identify their associated factors among home-living older Chinese adults in Hong Kong. METHODS: This is a cross-sectional study, to which home-living subjects aged 60 or above were recruited, between May and September 2017, from a non-governmental community organisation located in three different districts of Hong Kong. Nutritional status was assessed by the Mini Nutritional Assessment (MNA), and its associated factors examined included socio-demographic characteristics, lifestyle, health status and diet. Multivariable logistic regression analysis was performed to identify factors associated with malnutrition risks (MNA < 24). RESULTS: Six hundred thirteen subjects (mean age: 78.5 ± 7.4; 54.0% females) completed the survey. Nearly 30% (n = 179) were at risk of malnutrition. By multivariable logistic regression, subjects (1) whose vision was only fair or unclear, (2) with poor usual appetite and (3) with main meal skipping behaviour had significantly higher malnutrition risk (all p < 0.05). CONCLUSIONS: In this affluent Chinese society, the malnutrition risk in older adults is close to the global average, which is a matter for much concern. Interventions are therefore warranted that target vulnerable groups with poor vision, appetite, and meal skipping behaviour. TRIAL REGISTRATION: Not applicable.

Integrated and simplified approaches to community management of acute malnutrition in rural Kenya: a cluster randomized trial protocol.

BACKGROUND: In many low income countries, the majority of acutely malnourished children are either brought to the health facility late or never at all due to reasons related to distance and associated costs. Integrated community case management (iCCM) is an integrated approach addressing disease and malnutrition through use of community health volunteers (CHVs) in children under-5 years. Evidence on the potential impact and practical experiences on integrating community-based management of acute malnutrition as part of an iCCM package is not well documented. In this study, we aim to investigate the effectiveness and cost effectiveness of integrating management of acute malnutrition into iCCM. METHODS: This is a two arm parallel groups, non-inferiority cluster randomized community trial (CRT) employing mixed methods approach (both qualitative and quantitative approaches). Baseline and end line data will be collected from eligible (malnourished) mother/caregiver-child dyads. Ten community units (CUs) with a cluster size of 24 study subjects will be randomized to either an intervention (5 CUs) and a control arm (5 CUs). CHV in the control arm, will only screening and refer MAM/SAM cases to the nearby health facility for treatment by healthcare professionals. In the intervention arm, however; CHVs will be trained both to screen/diagnose and also treat moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) without complication. A paired-matching design where each control group will be matched with intervention group with similar characteristics will be matched to ensure balance between the two groups with respect to baseline characteristics. Qualitative data will be collected using key informant and in-depth interviews (KIIs) and focused group discussions (FGDs) to capture the views and experiences of stakeholders. DISCUSSION: Our proposed intervention is based on an innovative approach of integrating and simplifying SAM and MAM management through CHWs bring the services closer to the community. The trial has received ethical approval from the Ethics Committee of AMREF Health Africa - Ethical and Scientific Review Committee (AMREF- ESRC), Nairobi, Kenya. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, and presented to local and international conferences. TRIAL REGISTRATION: PACTR201811870943127 ; Pre-results. 26 November 2018.

Do nutrition and cash-based interventions and policies aimed at reducing stunting have an impact on economic development of low-and-middle-income countries? A systematic review.

BACKGROUND: Childhood stunting is the most common manifestation of chronic malnutrition. A growing body of literature indicates that stunting can have negative repercussions on physical and cognitive development. There are increasing concerns that low- and middle-income countries (LMICs) are particularly susceptible to adverse consequences of stunting on economic development. The aim of this review is to synthesize current evidence on interventions and policies that have had success in reducing stunting and explore the impact of successes on economic indicators. METHODS: This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were searched through MEDLINE via PubMed and Ovid, Cochrane Library, Web of Science and ProQuest. Only articles that addressed the effects of nutrition and cash-based interventions and/or policies on stunting and reported effects on childhood mortality and/or human capital indicators were included. Two reviewers independently abstracted data and assessed quality. RESULTS: Seventeen studies from Africa (47%), South America (41%), and South Asia (12%) met the eligibility criteria: 8 cohort studies, 4 case studies, 4 Randomized Control Trials (RCTs) and 1 quasi-trial. Three types of interventions/policies were evaluated: multisectoral policies, nutritional supplementations and cash-based interventions (CCT). Overall, 76% of the included studies were successful in reducing stunting and 65% of interventions/policies reported successes on stunting reductions and economic successes. Five of the 11 successful studies reported on nutritional supplementation, 4 reported on multisectoral policies, and 2 reported on CCT interventions. Average Annual Rate of Reduction (AARR) was calculated to assess the impact of multisectoral policies on childhood mortality. AARR for under 5 mortality ranged from 5.2 to 6.2% and all countries aligned with the global target of 4.4% AARR. Quality assessment yielded positive results, with the biggest concerns being attrition bias for cohort studies, blinding for trials and generalizability of results for case studies. CONCLUSIONS: Evidence suggests that investment in fighting chronic malnutrition through multisectoral policies, multi-year nutritional supplementation (protein or multiple micronutrient supplementation) and possibly CCTs can have a long-term impact on economic development of LMICs. More evidence is needed to inform practices in non-represented regions while prioritizing standardization of economic indicators in the literature.

Impact of nutritional status on length of stay and hospital costs among patients admitted to a tertiary care hospital in Thailand.

BACKGROUND AND OBJECTIVES: Malnutrition has high prevalence among hospitalized patients but goes unrecognized in many patients. Early detection of malnutrition using an effective screening tool is required. This study aimed to examine the effects of nutritional status determined by the Nutrition Alert Form (NAF) and its individual sections on length of stay (LOS) and hospital costs in hospitalized patients, to investigate their associated factors, and to determine hospital malnutrition prevalence. METHODS AND STUDY DESIGN: This retrospective cohort study enrolled 2,906 hospitalized patients aged >=15 years in Ramathibodi Hospital between January and September 2016. At admission, nutritional status was screened using NAF. Nutrition status was defined as: NAF-A (normal/mild malnutrition; scores of 0-5), NAF-B (moderate malnutrition; 6-10), and NAF-C (severe malnutrition; >=11). Information regarding LOS and hospital costs during patients' hospitalization was also collected. RESULTS: The prevalence of malnutrition was 15.3%. After adjusting for age, sex and primary diagnosis, we found significantly longer LOS and higher hospital costs among those with NAF-B and NAF-C, in comparison with patients having NAF-A. The highest increase in LOS was in male patients aged >=60 years with NAF-C. The highest increase in LOS and hospital costs was associated with higher scores for functional capacity. CONCLUSIONS: Higher levels of malnutrition screened using the NAF were significantly associated with longer LOS and higher hospital costs. Older adult patients had the highest risk of being malnourished and developing negative consequences. A prospective study of nutritional support by a nutrition care team is underway.

Clinical and financial implications of hospital malnutrition in Spain.

OBJECTIVE: The aim of this review is to analyse the studies about cost and clinical implications that malnutrition causes in the Spanish hospitals. MATERIAL AND METHODS: The review of the literature was carried out through a bibliographic search in Web of Science following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria and analyse the cost of treatment of malnourished and anorexia nervosa (AN) patients RESULTS: Seventeen studies with economic data related to malnutrition were included. The employment of a nutritional screening is the first tool to determinate the prevalence. Malnutrition is related to an incremental cost due to a longer hospital stay, expensive treatment, and higher rate of readmissions. Malnourished patients present more clinical complications, more infections, and higher mortality. No studies were found with economic data of AN in Spain. CONCLUSIONS: The prevalence of malnutrition is over 20%, with the elderly patients being the most affected. Nutritional screening is not implanted in all Spanish hospitals in spite of its proven cost-effectiveness. The cost and the clinical implications of malnutrition make this disease a health national problem. The knowledge of the real cost of AN treatment would increase the interest of public institutions on the development of specific Nutritional Screening tools for an early detection of AN.

Cost-effectiveness of food, supplement and environmental interventions to address malnutrition in residential aged care: a systematic review.

Background: observational studies have shown that nutritional strategies to manage malnutrition may be cost-effective in aged care; but more robust economic data is needed to support and encourage translation to practice. Therefore, the aim of this systematic review is to compare the cost-effectiveness of implementing nutrition interventions targeting malnutrition in aged care homes versus usual care. Setting: residential aged care homes. Methods: systematic literature review of studies published between January 2000 and August 2017 across 10 electronic databases. Cochrane Risk of Bias tool and GRADE were used to evaluate the quality of the studies. Results: eight included studies (3,098 studies initially screened) reported on 11 intervention groups, evaluating the effect of modifications to dining environment (n = 1), supplements (n = 5) and food-based interventions (n = 5). Interventions had a low cost of implementation (<£2.30/resident/day) and provided clinical improvement for a range of outcomes including weight, nutritional status and dietary intake. Supplements and food-based interventions further demonstrated a low cost per quality adjusted life year or unit of physical function improvement. GRADE assessment revealed the quality of the body of evidence that introducing malnutrition interventions, whether they be environmental, supplements or food-based, are cost-effective in aged care homes was low. Conclusion: this review suggests supplements and food-based nutrition interventions in the aged care setting are clinically effective, have a low cost of implementation and may be cost-effective at improving clinical outcomes associated with malnutrition. More studies using well-defined frameworks for economic analysis, stronger study designs with improved quality, along with validated malnutrition measures are needed to confirm and increase confidence with these findings.

Economic policy and the double burden of malnutrition: cross-national longitudinal analysis of minimum wage and women's underweight and obesity.

OBJECTIVE: To examine changes in minimum wage associated with changes in women's weight status. DESIGN: Longitudinal study of legislated minimum wage levels (per month, purchasing power parity-adjusted, 2011 constant US dollar values) linked to anthropometric and sociodemographic data from multiple Demographic and Health Surveys (2000-2014). Separate multilevel models estimated associations of a $10 increase in monthly minimum wage with the rate of change in underweight and obesity, conditioning on individual and country confounders. Post-estimation analysis computed predicted mean probabilities of being underweight or obese associated with higher levels of minimum wage at study start and end. SETTING: Twenty-four low-income countries. SUBJECTS: Adult non-pregnant women (n 150 796). RESULTS: Higher minimum wages were associated (OR; 95 % CI) with reduced underweight in women (0·986; 0·977, 0·995); a decrease that accelerated over time (P-interaction=0·025). Increasing minimum wage was associated with higher obesity (1·019; 1·008, 1·030), but did not alter the rate of increase in obesity prevalence (P-interaction=0·8). A $10 rise in monthly minimum wage was associated (prevalence difference; 95 % CI) with an average decrease of about 0·14 percentage points (-0·14; -0·23, -0·05) for underweight and an increase of about 0·1 percentage points (0·12; 0·04, 0·20) for obesity. CONCLUSIONS: The present longitudinal multi-country study showed that a $10 rise in monthly minimum wage significantly accelerated the decline in women's underweight prevalence, but had no association with the pace of growth in obesity prevalence. Thus, modest rises in minimum wage may be beneficial for addressing the protracted underweight problem in poor countries, especially South Asia and parts of Africa.

The Double Burden of Malnutrition in Countries Passing through the Economic Transition.

Undernutrition in both its acute and chronic forms (wasting and stunting) is strongly inversely correlated with the wealth of nations. Consequently, as many low- and middle-income countries (LMICs) achieve economic advancement and pass through the so-called "nutrition transition," their rates of undernutrition decline. Many countries successfully achieved the Millennium Development Goal of halving undernutrition and whole continents have been transformed in recent decades. The exception is Africa where the slower rates of decline in the prevalence of undernutrition has been overtaken by population growth so that the absolute number of stunted children is rising. In many regions, economic transition is causing a rapid increase in the number of overweight and obese people. The rapidity of this rise is such that many nations bear the simultaneous burdens of under- and overnutrition; termed the "double burden" of malnutrition. This double burden, accompanied as it is by the unfinished agenda of high levels of infectious diseases, is crippling the health systems of many LMICs and thus requires urgent attention. Although the prognosis looks threatening for many poor countries, they have the advantage of being able to learn from the mistakes made by other nations that have passed through the transition before them. Concerted action across many arms of government would achieve huge future dividends in health and wealth for any nations that can grasp the challenge.